Navigating the Dobbs versus Jackson America for Patients with CKD and Kidney Transplants
Authors: Jessica C. Morgan, Bethany J. Foster, Amanda J. Vinson, Germaine Wong, Krista L. Lentine, Lori J. West, Anita S. Chong, Anne Halpin, Roslyn B. Mannon
Journal: Journal of the American Society of Nephrology (2023)

The Dobbs v. Jackson Women's Health US Supreme Court decision on June 24, 2022, upended the constitutional protection for patients' access to abortion afforded by the Roe v. Wade decision of 1973, and reaffirmed by the Planned Parenthood v. Casey Supreme Court case of 1992. Protection is now relegated to the decisions of individual states despite these prior cases explicitly affirming and reaffirming protection at a federal level.1 This overruling of Roe has launched a cascade of events in which some states moved quickly to sharply restrict or completely ban abortion, while other states maintained protection of abortion services and prepared to expand access to those in need.2 Antiabortion activists promulgate that "abortion is still legal when the pregnant person's life is in danger." But what does such a stipulation mean? Does harm have to be imminent and life-threatening? Does having a debilitating disease—such as CKD or a kidney transplant—which chronically threatens the mother's well-being justify allowing termination of the pregnancy? For patients with kidney disease, pregnancy is a potentially dangerous condition. While CKD affects only 3% of pregnancies, CKD is associated with higher rates of fetal complications including miscarriage, stillbirth, fetal growth restriction, and preterm delivery, as well as maternal complications such as preeclampsia and worsening kidney dysfunction compared with pregnancies without CKD. Preeclampsia and other hypertensive disorders of pregnancy can lead to significant morbidity and mortality.3 Pregnancy with CKD may precipitate life-long consequences including accelerating progression to kidney failure, or rejection/graft failure in patients with a transplant. Furthermore, the possibility of extremely preterm delivery burdens both the health care system and families, not only during pregnancy and delivery, but for many years to come.4 One systematic review estimated the weighted adverse pregnancy outcomes in patients with CKD is at almost six times higher than people without kidney disease, with an absolute risk of 12% compared with the age-matched general population risk of 2%.5 If considering pregnancy, it is imperative for patients with CKD to have multidisciplinary care with nephrology, maternal fetal medicine, and potentially anesthesia and neonatology to optimize outcomes. This requires patients to have access to and ability to engage in health care, which is not guaranteed or feasible for many people of reproductive age, particularly those affected by systemic racism, facing socioeconomic barriers, or living in areas that make access to health care challenging. Disproportionately, this population of patients will be most negatively affected by the Dobbs decision.6,7 To date, the Transplant Pregnancy Registry contains pregnancy outcome information on 1251 kidney transplant recipients who had subsequent pregnancies, 30% of which were unplanned.8Termination of pregnancy is reported in 4% of pregnancies although this may be an underestimate. The rate of preterm birth is significantly higher than in the general population (37% versus 10%–12%), as is the rate of Cesarean delivery (51% versus 31%). The TPR quotes a maternal death rate of 18% in the 14 years following pregnancy, with the mean age of children at time of their mothers' death being 17 years old. Thus, while pregnancy is possible in patients with a transplant, these data highlight the risks associated with pregnancy in recipients.8 The importance of multidisciplinary care including maternal-fetal medicine is highlighted as well. Access to high-risk obstetric care is not possible for all patients, and the number of hospitals providing maternity care in rural areas of the United States continues to decline, creating so-called "maternity deserts."9 Indeed, 90% of counties in the United States do not have any abortion provider available or accessible.10 This places all patients, but especially high-risk patients such as those with kidney disease or transplant at a disadvantage, with no qualified obstetric provider nearby to manage their immunosuppression and pregnancy, thus leading to adverse outcomes10 (Figure 1).Figure 1: Access to reproductive health services and implications to patients with kidney disease and kidney transplants.Some patients with CKD and kidney failure requiring renal replacement therapy may choose an abortion as pregnancy incurs significant health. Many patients with unexpected pregnancy are faced with added medical complexity including the need for more intensive dialysis, control of anemia and nutritional deficits, and specific care to avoid infections. For those on the kidney transplant wait list, there is a risk of death associated with deferring a transplant opportunity during pregnancy. Pregnancy also increases the risk of HLA sensitization, making compatible donors more challenging to find.11 Current clinical practice guidelines for the care of pregnancies in patients with CKD do not outline specific options on induced termination of pregnancy but suggest an open dialogue to consider the patients' preferences, perspectives, and needs, and allow for individualized risk counseling and optimization of health.4 Respect for autonomy of pregnant people with CKD requires eliciting the pregnant person's fears, desires, and beliefs, and ultimately supporting their preferences and values. The tenet of the health care system is predicated on dual concepts of "do no harm" embedded in the Hippocratic Oath and patient autonomy. By removing access to care for a patient population already experiencing challenges accessing high-quality medical care, patients with CKD or kidney transplants, or on dialysis, and their care providers are likely to face additional challenges in the near future. An additional result of post-Dobbs changes in state legislation is increased legal liability for physicians who support and protect their patients in highly vulnerable situations. The threat of legal action may handicap well-intentioned providers and their ability to provide the best care possible to their patients.5,10 Among patients seeking out abortion services, lower socioeconomic status is associated with barriers to care access and may further complicate care of our patients with kidney disease. Even in states with protection of and access to abortion care, federal funding (Medicaid and Medicare) often cannot be used to fund abortions. This leaves patients to either self-fund the service, transportation, and lodging required or apply for grants from abortion funds. Federal funding is available for certain services such as contraception and sexually transmitted infection testing through the Title X Family Planning Program but is expressly prohibited from being used for the counseling, referral, or performance of abortion services.12 It is known that health care access and cost barriers are a common thread throughout our system in the United States, and do not only plague patients seeking reproductive health care, but a spectrum of medical conditions. We can already measure the impact of abortion restriction on medically uncomplicated pregnancies. A recent study conducted following abortion restrictions in Texas starting in 2021 evaluated outcomes in pregnancies <22 gestation weeks with complications such as preterm rupture of membranes, hemorrhage, and infection. The maternal morbidity was nearly doubled for patients denied abortion and forced to undergo expectant management compared with those who were able to immediately interrupt their pregnancy. If the goal of restricting abortion is to ensure that each pregnancy results in a live birth, this was not achieved; this study showed no significant improvement in neonatal outcomes with continued pregnancy and instead highlighted the potential for maternal harm without neonatal gain.13 Given that maternal morbidity worsened even in low-risk/healthy individuals, the threat facing high-risk patients is predicted to be much greater. The barrier to abortion access is a health care crisis that will have downstream effects we cannot yet fully quantify—and represents an ever-changing landscape both in the United States and globally—as new amendments and protections are put to vote in continuing elections (Supplementary Table 1). While the issue of abortion rights has undoubtedly become politicized over the years and is charged with moral and religious rhetoric, as health care professionals, we must remain focused on our patients. The right to maintain bodily autonomy is now at risk and even banned in many states; people who can become pregnant are no longer able to choose to maintain their health and to mitigate further harm. Freedom of choice is a principle we must champion as clinicians of patients experiencing pregnancy in the context of complex medical issues. As clinicians, the ability to make meaningful change on a large scale can seem daunting, and the channels to do so are not always obvious. We recommend to continue providing evidence-based care to patients on an individual level and to provide appropriate care guided by the principle of beneficence at all times. On a larger scale, there are opportunities to become involved in advocacy on a state-wide, regional, or national level, through a variety of organizations—such as those who issued position statements after the Dobbs decision (Supplementary Table 2). Advocacy can be defined as providing medical care for patients and fighting for their right to equal care, calling legislators, going to individual state capitols for advocacy events, or even being involved with physician groups or professional societies lobbying at a national level. Similar opportunities exist to engage in advocacy internationally, as ensuring universal standards of health care access truly is a global concern and affects patients and clinicians everywhere.